Vaginal Dryness in Menopause: Understanding GSM

More than half of postmenopausal women have it. Fewer than one in five are treated for it. The gap is not a medical failure so much as a conversational one.

It is not only vaginal

The condition was renamed genitourinary syndrome of menopause for a reason. Estrogen receptors are present throughout the vulva, the vagina, the urethra, and the bladder trigone, and all of that tissue changes together when estrogen falls.

That is why a woman may present with what looks like three separate problems and have one underlying cause:

• Dryness, burning, and itching that is present whether or not she is sexually active.
• Urinary urgency and frequency, and getting up at night to urinate.
• Recurrent urinary tract infections, which rise sharply after menopause as the protective vaginal flora shifts.
• Pain with intercourse, and light bleeding from fragile tissue.

Recurrent urinary tract infections after menopause are frequently a genitourinary syndrome problem being treated as an infection problem, one course of antibiotics at a time.

Why it does not resolve on its own

Vasomotor symptoms are driven by hormonal instability, and they settle as the body adapts to a new baseline. Genitourinary symptoms are driven by the absence of estrogen in the tissue, which is permanent. Without treatment, the tissue continues to thin. Women who wait often find the condition harder to reverse than it would have been at the start.

The treatment ladder

Non hormonal first line. Vaginal moisturizers applied two or three times weekly, used regularly rather than only around intercourse. Silicone or water based lubricants for friction. Avoiding scented soaps, washes, and wipes on vulvar skin, which are a common and overlooked source of irritation.

Local estrogen. Available as a cream, a tablet, or a ring. Systemic absorption is minimal, and major professional bodies support its use even in many women with contraindications to systemic hormone therapy, though the decision after breast cancer should always be individualized with the treating oncologist. Improvement in urinary symptoms and infection recurrence is well documented.

Alternatives. Vaginal DHEA, and a selective estrogen receptor modulator taken orally for women who prefer to avoid vaginal application.

Set expectations correctly

Tissue takes eight to twelve weeks to respond, and the most common reason treatment appears to fail is that it was stopped at three weeks. It is also ongoing therapy rather than a course. Symptoms return within months of stopping, because the underlying estrogen deficiency has not changed.

What should always be examined

Any bleeding after menopause requires evaluation, and should never be assumed to be from dryness. Persistent itching, white patches, or a change in the shape of the vulvar tissue may indicate lichen sclerosus, which needs a different treatment and follow up.